Provider Demographics
NPI:1275151623
Name:STORRS, MALLORY CLARE (MBA, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:CLARE
Last Name:STORRS
Suffix:
Gender:F
Credentials:MBA, RD, LD
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:CLARE
Other - Last Name:PIONTKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6112 W 123RD ST
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1805
Mailing Address - Country:US
Mailing Address - Phone:708-341-8789
Mailing Address - Fax:
Practice Address - Street 1:10631 PALOS WEST DR
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1598
Practice Address - Country:US
Practice Address - Phone:708-341-8789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005527133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered